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The kratom bomb—DEA moves to fast-track scheduling herbal drug

15th September 2016

Rebecca Cooney

North American Executive Editor for The Lancet | @BekRx

The U.S. Drug Enforcement Agency’s rather controversial decision not to re-schedule marijuana as a schedule 2 drug received a flurry of recent attention, and another plant-based drug—kratom—is facing a related fate.

The DEA has indicated that it is working to expedite the temporary classification of the alkaloids mitragynine and 7- hydroxymitragynine, two of the main active constituents of the plant kratom, as schedule 1 drugs under the Controlled Substances Act. Substances in schedule 1 are considered those which have a high potential for abuse and which are not accepted as safe or effective for medical treatment or under medical supervision.

With the expedited classification targeted for September 30, 2016, the backlash from kratom users and supporters has begun to intensify. This week, proponents of the herb held a rally in Washington, DC and submitted a 120,000-signature petition to the White House opposing the DEA’s plans and asking for an open comment period that would allow experts and the public to weigh in.

Kratom, like many other unregulated herbal supplements, has the cache of east meets west. Used as a folk remedy in countries such as Thailand, kratom leaves are harvested from a tree in the coffee family and commonly steeped as tea or consumed in capsules. In small amounts, kratom is purported to have a stimulant effect, but in larger amounts, it works as a sedative.

Although kratom is still used in traditional medicine in Southeast Asia where it is grown, such as for the treatment of diarrhea or as a local anesthetic, its popularity in the west has primarily been recreational or as an opioid substitute to ease withdrawal symptoms or for chronic pain. It is in that capacity that kratom has risen to notoriety and flagged the attention of the DEA as well as the CDC. In a Morbidity and Mortality Weekly Report issued earlier this summer, a CDC study found that from 2000-2015, U.S. poison centers received 660 calls related to kratom, with nearly a half of reported cases requiring medical attention for either moderate or more severe symptoms, including tachycardia and nausea. Two deaths were reported. The report concludes with the suggestion that kratom use is an emerging public health threat—a sentiment echoed by the DEA.

Supporters of the use of kratom for easing opioid addiction or withdrawal allege that that it is an unfair characterization, especially in light of the serious opioid epidemic in the US. For perspective, about 28,000 people died from opioid overdoses in 2014 alone. Critically, there is little clinical evidence to support a legitimate medicinal role for kratom. But, as the case has been with marijuana, there is also the difficulty of obtaining high-quality evidence with the impending schedule 1 designation, which will make studies investigating kratom that much more difficult to conduct. Without clinical support for the safety and efficacy of kratom, it is unlikely that the DEA’s decision will be circumvented. For many kratom users who have espoused the protest, “We are the ones in pain”, after this decision, relief may remain out of reach.